Osteoporotic Compression Fracture and Percutaneous Vertrebroplasty dr.sandeep c agrawal agrasen hospital gondia maharashtra india

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Osteoporotic Compression Fracture
And Percutaneous Vertebroplasty 
Loss of body Height
Kyphotic deformity
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
www.agrasenortho.com
drsandeep123@gmail.com

Osteoporotic Compression Fracture
1.Most can be treated by
bed rest, brace, and analgesics
!
2.Rarely surgically treated –
High complications rate by implant
fixation
!
3.Alternative - Minimally Invasive
Method

Percutaneous Vertebroplasty
●Deramond 1984 – Vertebra Hemangioma

4
Vertebral Compression Fracture
Thoracic: wedge by kyphotic loading
!
Lumbar: central endplate cupping
!
!
MRI: high sensitivity
Bone scan
Sagittal reconstructed CT images

5
Imaging guided percutaneous spine
intervention.
!
For painful benign or malignant, pathologic
vertebral fracture.
Vertebroplasty

6
Confirmed by X-ray & MRI
!
Pain corresponding to level of the fracture
!
Unresponsive to conservative treatment
Patient Selection Criteria

7
Contraindications
Uncorrected coagulopathy
!
Infection – local or systemic
!
Moderate or severe retropulsion of posterior
vertebral body cortex into spinal cord
!
Vertebra plana: Height loss > 80%

8
Procedures
General or local anesthesia
!
Prone position (posture reduction)
!
Unilateral or bilateral transpedicular
approach under fluroscopic control
!
Cement - barium sulfate mixture

9
Introduction 
(Percutaneous vertebroplasty )
Galibert and Deramond in 1987
( vertebral angioma )!
Lapras in 1989 ( osteoporotic
compression fracture )!
Decreasing the pain and improving the
function !
Beneﬁt from this procedure is uncertain

10
Procedure
Route chosen !
Cement leakage !
Nonevident!
Epidural plexus!
Lumbar venous plexus!
Adjacent disc!
Epidural space !
Postprocedural complications

11
Radiologic
Number of vertebral levels !
!
Percentage loss of vertebral height !
Distance (endplate to endplate) at center of vertebral body !
!
Height of vertebra above fractured vertebra =>!
!
Estimation of the prefracture height !
Height lost = (fractured height/estimated prefractured
height) × 100

12
Radiologic
Location of the vertebral level !
T spine :T1 - T10!
TL junction : T11 - L2!
L spine : L3 - L5 !
Type of deformity (wedge, biconcave, or
compression) and osteonecrosis

13
Height loss associated with
unfavorable result!
71.4% in vertebrae with a height loss
higher than 70%

14
Leakage into disc associated with worse
result

Imaging Guided Percutaneous Spine
Intervention.
!
New Treatment for Painful Benign or
Malignant Vertebral Compression
Fracture

17

85 year male, low back pain
after trauma for one year
L1 compression
Fracture

T12 compression Fracture with nonunion

74 Year female, T11 T12 L1
Multiple Compression Fractures

Minimal invasive method

Stabilize the fracture vertebra

Dramatic Decreased back pain

=> Improved life quality

Pain Relief in Vertebroplasty
Prevention of micromotion

!
Mechanical stabilization

!
Monomer cytotoxicity or exothermic
reaction

- Thomas A. Einhorn. Spine  
vol 25. no. 9 -

Complications of Vertebroplasty
Cement leakage

Adjacent new compression fracture

Pulmonary embolism

Infection

● Subcutaneous hematoma
● Neurological deficit

Cement Leakage
34~75%
Not generally lead to complications
Possible paraplegia
! ! ! ! ! ! ! - OKU 7 -

Pulmonary Embolism

Increase Fracture Risk at  
Adjacent Vertebrae
Additional new fractures
within one year - 15 %
(46/300 patients)!
Garﬁn et al, Eurospine 2001

Risks for Adjacent Fracture
Adjacent fracture is not
associated with age, sex,
fracture level, bone mineral
density, cement volume and
kyphotic angle.
- Chen APOA 2004

28
Adjacent level fracture

Adjacent Fracture  
After Vertebroplasty
Natural course of disease
Provoked by an adjacent rigid
reinforcement.
Mechanism : 
Combination of the underlying condition ,
osteoporosis , neoplastic disease , hard cement in the
disc , increased activities after vertebroplasty

30
Vertebroplasty : Cement Leakage into the Disc
Increases the Risk of New Fracture of Adjacent
Vertebral Body
AJNR
Am
J
Neuroradiology
25
,
February
2004

 
Edward
P.Lin,
Sven
Ekholm,
Akio
Hiwatashi,
and
Per-Lennart
Westesson

Department
of
Radiology,
Division
of
Diagnostic
&
Interventional

Neuroradiology
,
 
University
of
Rochester
Medical
Center,
Rochester
,
New
York 
Mechanism : 
Combination of the underlying condition ,
osteoporosis , neoplastic disease , hard
cement in the disc , increased activities after
vertebroplasty

31
Discussion
The amount of cement injected during vertebroplasty 
The amount of cement that leaked into the disc  
 
 
 
 
The incidence of new fractures 
 
 
 
 
Require further studies

32
Discussion
We should attempt to reduce the incidence and the
amount of cement leakage into the disc during
vertebropalsty :  
!
The needle tip location – laterally , not centrally
 
The consistency of the cement – more viscous
 
The volume of cement injected – smaller volume
 
Stopping injection when detecting leakage into 
disc , resumed after cement slightly hardened

33
Discussion
Supplementary Vertebroplasty + 
Posterior instrumentation and P-L fusion
Avoid anterior procedures  
Provide sufficient axial loading of vertebral body 
Prevent implants failure

Efficacious (but not a risk free) in
pain reduction (86%) for painful
osteoporotic spine fracture
Skillful techniques and careful
safeguards can minimize the
complications

35
Discussion
Percentage of excellent results decrease in > 70% loss of
vertebral height!
!
Difﬁcult technically!
!
High incidence of disc leakages!
!
Complete relief ＜ 30% (29.6%) of the patients !
!
Progression of the fracture is evident => PV!
!
Fracture remains stable => keep conservative treatment

36
Discussion
Involvement of > 2 segments was
associated with worse outcome!
!
Disseminated disease and multiple
level fractures are less likely to be free
of pain after a PV

Conclusions
Appropriate patient selection
is essential for achieving
clinical success
Back pain is correlated to
image study esp. MRI

Conclusions
Better results can be expected
in patients with an ASA score
of I and the vertebral body
height loss is less than 70%.

39
Have Fun!
!
!
In our busy daily lives, most of us have!
forgotten one of the bare essentials of!
a happy life - having fun!!
!
!
Be silly. Crack jokes. Laugh. Be mischievous.!
Let your hair down. Leave your troubles!
behind. Play hard. Just play.!
Enjoy yourself.!
!
!
We are always so busy walking and running!
in our lives, we forget. We forget to stop!
and dance!!

Osteoporotic Compression Fracture and Percutaneous Vertrebroplasty dr.sandeep c agrawal agrasen hospital gondia maharashtra india

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Osteoporotic Compression Fracture and Percutaneous Vertrebroplasty dr.sandeep c agrawal agrasen hospital gondia maharashtra india